HospitalInspections.org

Based on policy review, clinical record review, and interview, it was determined the facility failed to ensure one (#5) of three (#5, #8, and #13) patients with wounds were turned every two hours per policy. Failure to turn Patient #5 every two hours resulted in skin breakdown and a stage 2 bedsore. The failed practice had the likelihood to affect any patient at risk of skin breakdown. Findings follow.

A. Review of policy titled, "Skin Integrity, Care of the Patient With or At Risk for Impairment" showed Braden Skin Assessments were to be completed once per shift and more often if there was a change in the patient's condition. Under "Interventions" the policy stated, "Patients with intact skin and a Braden score of 16 or LESS or have a diagnosis that deems them high risk ....are to have preventive measures implemented to include: ...Turn patient every two hours; inspect pressure points for signs of redness."

B. Review of Braden scores for Patient #5 showed the following:
06/25/18 at 12:40 AM - 19, at 8:30 AM - 17, at 3:00 PM - 14, at 7:47 PM - 13
06/26/18 at 7:46 AM - 17, at 7:37 PM - 14
06/27/18 at 7:22 AM - 13, at 7:00 PM - 13
06/28/18 at 7:30 AM - 12, at 7:00 PM - 12
06/29/18 at 7:00 AM - 11, at 7:00 PM - 11
06/30/18 at 7:00 AM - 10, at 7:00 PM - 10
07/01/18 at 7:00 AM - 10, at 9:00 PM - 11
07/02/18 at 6:40 AM - 11, at 11:00 AM - 11, at 3:00 PM - 11, at 8:22 PM - 11
07/03/18 at 7:00 AM - 11, at 7:30 PM - 12
07/04/18 at 7:05 AM - 10, at 11:00 AM - 10, at 3:00 PM - 10, at 7:00 PM - 11
07/05/18 at 7:00 AM - 11, at 11:00 AM - 11, at 3:00 PM - 11, at 7:00 PM - 11
07/06/18 at 7:00 AM - 10, at 7:00 PM - 9
07/08/18 at 7:00 AM - 11
07/09/18 at 7:00 PM - 13
07/10/18 at 7:00 AM - 13, at 7:00 PM - 12
07/11/18 at 7:00 AM - 12, at 8:45 PM - 12
07/12/18 at 7:00 AM - 10, at 8:00 PM - 12
07/13/18 at 7:00 AM - 9, at 7:55 PM - 12
07/14/18 at 7:00 PM - 12
07/15/18 at 7:00 AM - 12, at 8:10 PM - 12
07/16/18 at 7:00 AM - 12, at 10:14 PM - 13
07/17/18 at 7:00 AM - 13, at 8:48 PM - 13
07/18/18 at 7:00 AM - 10, at 9:00 PM - 9
07/19/18 at 7:00 PM - 14
07/20/18 at 3:00 PM - 11
07/21/18 at 7:00 AM - 11, at 7:39 PM - 11
07/22/18 at 7:00 AM - 11, at 8:08 PM - 11
07/25/18 at 7:00 AM - 12, at 11:00 AM - 12, at 3:00 PM - 12
07/26/18 at 7:00 AM - 12, at 7:51 PM - 13, at 11:41 PM - 13
07/27/18 at 7:00 AM - 13, at 8:00 PM - 15
07/28/18 at 7:00 AM - 15
07/29/18 at 7:00 AM - 11, at 7:00 PM - 13
07/30/18 at 7:00 AM - 12, at 8:45 PM - 13
07/31/18 at 12:52 AM - 13, at 7:00 AM - 13, at 8:00 PM - 13
08/01/18 at 7:00 AM - 12, at 7:45 PM - 11
08/02/18 at 7:00 AM - 12, at 7:53 PM - 12

C. Patient #5's Braden scores were less than 16 from 06/26/18 at 7:37 PM through the remainder of her stay. Review of Skin Breakdown Prevention flowsheets showed the patient was not turned every two hours per policy during the following times:
From 4:00 PM on 07/20/18 through 7:00 AM on 07/21/18
From 7:00 PM on 07/21/18 through 7:00 PM on 07/22/18
From 4:00 PM on 07/23/18 through 7:00 AM on 07/24/18
From 3:00 PM on 07/24/18 through 7:00 AM on 07/25/18
From 1:00 PM on 07/26/18 through 12:00 AM on 07/27/18
From 3:00 PM on 07/27/18 through 8:00 AM on 07/28/18
From 4:00 PM on 07/28/19 through 10:00 AM on 07/29/18
From 6:00 PM on 07/30/18 through 7:00 AM on 07/31/18

D. Review of Result History showed the following:
07/04/18 at 11:00 AM - Small pea sized stage II sore noted to coccyx
07/06/18 at 7:00 PM - Stg (stage) 2 pressure ulcer, c/d/i, (clean/dry/intact), Mepilex
07/12/18 at 7:00 AM - Sacral breakdown
07/12/18 at 11:00 AM - Sacral breakdown, Mepilex in place
07/17/18 at 8:48 PM - Sacral wound

E. The findings in A-D were verified with the Market Director of Quality during an interview on 07/11/19 at 1:10 PM.

Based on observation, policy and procedure review and interview, it was determined the facility failed to mitigate the risk of infection in that one of one (#1) physician failed to wear Personal Protective Equipment (a gown and gloves) while interviewing Patient #14 who was on Contact Isolation. The failed practice promoted the spread of infection and had the likelihood to affect all patients in the facility. Findings included:

A. Review of the facility's policy titled, "Infection Prevention: Standard Precautions and Transmission Based Precautions," with an effective date of January 2001, showed Contact and Enteric Contact Precautions were intended to reduce the risk of transmission of epidemiologically significant microorganisms by direct or indirect contact. Contact Precautions were indicated for patients known or suspected of being infected or colonized with organisms that were easily transmitted through direct contact or by contact with items in the patient's environment. Personal Protective Equipment: put on gown and gloves before entering a Contact Isolation Area.

B. The findings of A were confirmed in an interview with the Market Director of Quality on 07/10/19 at 12:55 PM.

C. Observation of the Contact Precautions sign posted on Patient #14's door on 07/10/19 at 9:15 AM showed gown and gloves were to be worn when entering patient room.

D. Observation of Patient #14's room on 07/10/19 at 9:15 AM showed Physician #1 was performing an interview on Patient #14. Physician #1 was not wearing a gown or gloves.

E. The findings of C and D were confirmed in an interview with the Manager of the Critical Care Unit/2 East on 07/10/19 at 9:15 AM.